Do privileged US citizens have better health outcomes?

During the COVID-19 pandemic, privilege—or the lack thereof—and its effects on health have taken on considerable importance.

Privilege can manifest in disparities related to wealth, race, gender, and more. In the pandemic, for instance, the wealth gap between Black and White Americans remained strong, as White families held 84% of total household wealth in the United States. Analysts for the Brookings Institution claim that this gap placed Black families in a less desirable position when COVID-19 struck.

Some healthcare and political leaders are trying to level the playing field. The push for health equity has even sparked the government to invest $250 million in reducing disparities.

But do privileged US citizens actually have better health outcomes? And if so, what does that mean for everyone else, including the physicians who care for them?

Comparing privilege among countries

In 2020, JAMA Internal Medicine published a study examining health outcomes of White residents in America’s top 1% and 5% highest-earning counties against those of other developed nations, such as Australia, Denmark, and Japan. Researchers hoped to understand how the most well-off Americans fared when it came to global health outcomes, but they also uncovered plenty of insights about care at home.

The study examined infant mortality, maternal mortality, 5-year survival of patients with three types of cancer, and 30-day, age-standardized case fatality following acute myocardial infarction. Across all of these measures, White US citizens from wealthy areas experienced better health outcomes than the typical American.

For example, White residents of the 5% highest-earning counties who were diagnosed with colon cancer experienced a 5-year survival rate of 67.2%, compared with 64.9% among their neighbors. The White infant mortality rate in the top 1% of counties reached just 3.54 per 1,000 live births (lower than the 5.90 national average), while White women in the richest areas suffered a maternal mortality rate of 10.05 per 100,000 live births (again, less than the 26.40 national average). When it came to heart attacks, the case-fatality rate for the wealthiest counties ranged between 12.4 and 12.7%, falling short of the general population’s 13.4%.

The study spotlighted a striking statistic: The richest Americans receive 43% more care than the lowest-income patients and 23% more care than those of the middle class.

“Privileged White US citizens do obtain better health outcomes than average US citizens for 6 health conditions, while low-income US citizens have much worse outcomes,” the authors wrote.

But for all their privilege in the United States, wealthy White patients often had inferior health outcomes compared with the mean measure of health outcomes for 12 other developed countries: Australia, Austria, Canada, Denmark, Finland, France, Germany, Japan, the Netherlands, Norway, Sweden, and Switzerland. 

“These findings imply that even if all US citizens experienced the same health outcomes enjoyed by privileged White US citizens, US health indicators would still lag behind those in many other countries,” the authors wrote.

Racial minorities suffer worse health outcomes

Privilege, of course, means different things depending on the context. One manifestation is through race, as studies have repeatedly found that White patients achieve stronger health outcomes than people of color.

In a sweeping 2019 article published in Annual Reviews, researchers analyzed the body of evidence surrounding racism and its links to mental and physical health outcomes. The review focused on everything from the effects of residential segregation and stereotyping to discrimination’s imprint on mental health.

Supported by dozens of findings, the researchers argued that, “Evidence continues to accumulate, highlighting racism as a driver of multiple upstream societal factors that perpetuate racial inequities in health for multiple nondominant racial groups around the world.”

A couple of examples: Black people received later diagnoses, suffer higher mortality rates, and smaller survival rates for breast and lung cancers, thanks in part to segregation. Latinx women were more likely to give birth to babies with low birthweight a year after a large immigration raid, unlike their White neighbors.

But when a new casino began providing money to Native American families, thus lessening their income disparities, their adolescent children engaged in less aggressive and deviant behavior, and such disparities were eliminated among indigenous and White communities.

Social determinants of health are important

To dig deeper into poverty’s role—a key driver of the social determinants of health—we can look to the COVID-19 pandemic.

In a commentary published last summer in The Lancet, physicians noted that people experiencing homelessness faced greater risk of coronavirus infection due to their living arrangements and barriers to COVID-19 testing. What’s more, people who are exposed to cigarette smoke were more prone to severe symptoms, intensive care unit admissions, and ventilator use. Chronic conditions associated with social determinants of health also increased COVID-19 risk, while social distancing barred some families from obtaining free school lunches, which could lead to malnutrition and its increased risk of transmission.

Taken together, the aforementioned points make clear that privilege influences health outcomes. So, what can physicians do?

Advocates and researchers argue that addressing health inequities requires big changes, but the authors of a perspective published last year in Health Equity point to one shift that everyone can make: Acknowledge privilege as a social determinant of health. Just as a physician wants to know whether their patients live with a smoker or face food insecurity, it could be helpful to understand whether they lack certain economic or social capital.

After all, the authors suggest, privilege affects nearly every other social determinant—and health itself.